1164433181 NPI number — JAMES FRANK BOFFA M.D.

Table of content: JAMES FRANK BOFFA M.D. (NPI 1164433181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164433181 NPI number — JAMES FRANK BOFFA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOFFA
Provider First Name:
JAMES
Provider Middle Name:
FRANK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOFFA
Provider Other First Name:
JAMES
Provider Other Middle Name:
FRANK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1164433181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 RIDGE AVE STE 1223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-570-2040
Provider Business Mailing Address Fax Number:
847-733-5315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5140 N CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
SUITE 780
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60625-3645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-273-6810
Provider Business Practice Location Address Fax Number:
773-271-5532
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  036086529 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036086529 4 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5077503 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036086529 2 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001630046 . This is a "BC BS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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